Healthcare Provider Details

I. General information

NPI: 1619156502
Provider Name (Legal Business Name): CLINICAL PSYCHOLOGY ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 W CHESTNUT ST STE 100
BURLINGTON WI
53105-1200
US

IV. Provider business mailing address

197 W CHESTNUT ST STE 100
BURLINGTON WI
53105-1200
US

V. Phone/Fax

Practice location:
  • Phone: 262-763-9191
  • Fax: 262-763-7767
Mailing address:
  • Phone: 262-763-9191
  • Fax: 262-763-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1588
License Number StateWI

VIII. Authorized Official

Name: DR. DAVID WILLIAM THOMPSON
Title or Position: CLINIC DIRECTOR/OWNER
Credential: PHD
Phone: 262-763-9191